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From an interview Performance Strategies held with:
Donald Berwick, MD, MPP, FRCP
President and CEO
Institute for Healthcare Improvement (IHI)
With the 10th anniversary of the 1999 Institute of Medicine Report, "To Err is Human: Building a Safer Health System," Performance Strategies wanted to focus on how healthcare organizations are protecting patient safety today. Quality improvement is not only part of most hospitals' core mission, but is a strategic imperative in order to address new rules and policies that put reimbursement at risk. Providers no longer get paid for certain hospital-acquired conditions that are not present on admission and medical errors such as adverse drug events and never events.
For a perspective on efforts to improve patient safety today, we turned to one of the leading authorities on healthcare and quality improvement. Donald Berwick is President and CEO of the Institute for Healthcare Improvement (IHI), which was founded in 1991 to help lead the global improvement of healthcare. IHI's mission is to work "to accelerate improvement by building the will for change, cultivating promising concepts for improving patient care, and helping healthcare systems put those ideas into action."
Q: How can organizations prioritize healthcare quality improvement efforts — especially with reimbursement pressures from regulatory bodies and payors?
A: Organizations are battered by a sea of requirements, measurements and standards, and they face an uncertain future. Requirements from The Joint Commission and the Centers for Medicare & Medicaid Services drive cost containment and patient safety initiatives, but providers don't know what to focus on. At IHI, we call it "back to mission" — be patient-centered and focus on safety. Link everything back to the patient and the patient's family. All process redesigns should center on the patient.
IHI has developed the Improvement Map, which is a collection of the best knowledge available on the key process improvements that a health organization can implement to provide exceptional patient care and reduce the risk of patient harm. The processes are related to the Institute of Medicine's (IOM's) six aims for improving healthcare — making healthcare more safe, effective, patient-centered, timely, efficient, and equitable. IHI has identified 70 care-improvement processes, based on well-documented evidence in most cases, and on smaller-scale demonstration projects in others. To use the Improvement Map, a hospital may sort the processes by various dimensions, for example the specific IOM aim they would like to tackle.
The Improvement Map helps simplify and rationalize priorities for improving care processes. We say it helps in "sense making" — it makes sense of the world of improvement recommendations and "smoothes" the work. This allows the hospital to focus on fewer processes and standards, and makes it easier to get quality improvement efforts started.
Q: What role do you see for IT in supporting patient safety improvements?
A: IT can be really helpful if used and implemented correctly. IT can act as a reminder system, so that we need not rely on doctors' and nurses' memories. It can smooth communication and help with handoffs. And you also have to ensure that IT supports the processes in place and is adopted by staff. However, simply adding IT to a system of broken processes does not necessarily improve or fix those processes.
Q: Do you have any specific recommendations to reduce errors and protect patient safety?
A: For organizations in the early stage of quality improvement: IHI's 100,000 Lives and 5 Million Lives Campaigns provided resources and How-to Guides for 12 proven interventions, which, if implemented, help hospitals save lives and reduce harm to patients. These resources are available on IHI's website (www.ihi.org/campaign).
For the patient: Have someone with you to keep an eye on what's happening to you. Family can help patients by observing care and asking questions.
Q: Are you rolling out a new safety campaign this year?
A: The IHI Open School for Health Professions is a descendent of the 5 Million Lives Campaign. We started a virtual school for students in any healthcare profession, which features online resources and courses on quality improvement, patient safety, patient-centered care, and other core topics. Everything is online. Students take exams online and have a dialogue online. They have started Chapters on campuses all around the world, where they meet each other and talk about issues and process improvement from the student's perspective.
We've had an exciting development recently. A few IHI Open School students wanted to take part in the challenge posed by the 5 Million Lives Campaign and started an initiative for other students to ask hospitals to adopt the World Health Organization Surgical Safety Checklist. To date, 15,000 students have signed up, and there have been 10,000 downloads of the checklist from IHI's website.
The IHI Open School has been so successful that hospitals have asked us if practicing healthcare professionals can access the same resources. The answer is, of course: It's free and available to anyone online at www.ihi.org/openschool.
Q: In the preface to your book, Escape Fire, you said that over the years there are three core messages: "Focus on the suffering, build and use knowledge, and cooperate." Have we made progress?
A: There is a continuing focus on suffering and on building and using knowledge, but cooperation is the hallmark of any advancement. We are making progress, but I'm not satisfied. It's much too slow. We can have reliability — we can engineer errors out of the process.
We get reports from all over the world of organizations that are achieving amazing results. Sentara in Williamsburg, Virginia, has gone five years without a single incidence of ventilator-acquired pneumonia. Denver Health used Lean methodology to save more than $30 million.
Q: Will healthcare reform provide a boost to the quality movement?
A: I don't know yet. I'll withhold judgment until we know more about its implementation. There are some positives, like the initiatives that fund centers for innovation. There's some really interesting stuff going on that will help healthcare get safer and spread improvements to all organizations.
There's also going to be a push to safety and cost containment from reform. Stakes are rising. The government may eventually ask, "If Sentara can do away with ventilator infections, why wouldn't we ask everyone to do that?" It is logical. Also, more evidence will be coming out on unnecessary care.
Q: Where do you see healthcare delivery in five years?
A: I hope to see two levels of significant change. For quality and improvement, the IOM's six aims for improving healthcare should become strategically centered in organizations. The second level is in care integration.
Today, we have fragmented care — patients fall through the cracks, and we don't follow up on those with chronic conditions. Integrated structures "smooth" the care experience. Bundled payments and new investments in connectivity will foster more integrated care, so patients don't feel lost. Patients want to be known, remembered. They want to know it's going to be OK.
It is now apparent that healthcare leaders and boards of directors are integral to securing safety for patients. You can get the workforce to improve safety, but to sustain it in the way the organization works, the board of directors needs to be firmly invested in patient safety and other dimensions of quality. If the importance of quality – which is just as crucial as financial health – is not centered in the board's strategic vision, then sustaining quality is impossible.
Donald M. Berwick, MD, MPP, FRCP, is President and CEO of the Institute for Healthcare Improvement (IHI) and is recognized as one of the nation's leading authorities on healthcare quality and improvement. He is also Clinical Professor of Pediatrics and Health Care Policy at the Harvard Medical School, and Professor in the Department of Health Policy and Management at the Harvard School of Public Health. Dr. Berwick has served as the first "Independent Member" of the Board of Trustees of the American Hospital Association, and chair of the National Advisory Council of the Agency for Healthcare Research and Quality. An elected member of the Institute of Medicine (IOM), Dr. Berwick served two terms on the IOM's Governing Council and was a member of the IOM's Global Health Board. He served on President Clinton's Advisory Commission on Consumer Protection and Quality in the Healthcare Industry.
Dr. Berwick has published several books and more than 140 scientific articles in numerous professional journals on subjects relating to healthcare policy and quality improvement. He has received numerous awards and honors, including the "Award of Honor" in 2002 from the American Hospital Association for outstanding leadership in improving healthcare quality. In 2006, he received the John M. Eisenberg Patient Safety and Quality Award for Individual Achievement from the National Quality Forum and The Joint Commission.
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According to the Institute for Healthcare Improvement (IHI), its most intensive front-line improvement work happens in its Collaboratives. The year-long, results-oriented programs are designed for organizations committed to achieving sustainable change within a specific area. Through workshops, online learning and teleconferences, highly credentialed faculty lead teams from a variety of organizations in the rapid testing of changes known to improve care, adapting them as necessary and constantly measuring outcomes.
One of the most popular collaboratives, Transforming Care at the Bedside, is now accepting new teams. The collaborative is designed to create new models of care delivery in medical-surgical units by engaging frontline staff, patients and families and by emphasizing teamwork to improve quality and staff retention. The program evolved from an initiative by the same name that was launched in 2003, by IHI and the Robert Wood Johnson Foundation, which has resulted in hundreds of organizations implementing its strategies around the globe.
Other collaboratives and learning communities focus on improving perinatal care, clinical office practice, patient flow, ED operations, and outcomes for high-risk and critically ill patients.
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